Delaware Technical Community College

NUR 320 Health Assessment

RN to BSN program: Plan of Care Chart

STUDENT NAME: _______Chloe_Conley___________________________ DATE: _____4/25/19__________

Nursing plan of care

Identified problem/need: Identified goal or Plan/ Interventions: Projected Evaluation/ Community Resources/
(include supporting outcome: (Provide rationale/ and Outcomes: (How will you Referrals: (Must be actual
subjective and objective cited evidence to justify measure that it worked?) resources from the
data) the rationale) client’s community.
Include Name, address,
web address, and phone
number)
Priority #1:
Diarrhea as told by To have formed, soft  Have patient keep a  Patient will report  https://www.bladdera
patient. Patient stated stools every 1-3 days. bowel diary of when he important information ndbowel.org/bowel/bo
they were having has a bowel movement on bowel movements wel-resources/bowel-
approximately 6 loose along with descriptions to further treat him. diary/ (link for a free
bowel movements per and information on  Eating small frequent bowel diary log)
day for about 2 days. food/fluid/medication meals will allow for  Gastrointestinal
intake to gather more easier digestion and Referral- GI Specialists
information if hopefully less stomach of Delaware, 900 Foulk
symptoms persist. irritation and diarrhea. Rd #200, Wilmington,
 Recommend patient Patient will maitain DE 19803
eat small frequent adequate fluid status Phone: (302) 832-1545
meals and encourage and show no signs of
fluid intake to maintain dehydration.

Priority #2:
Risk for development of
Type II Diabetes Mellitus
due to eating a high carb,
high fat diet per client as
well as a family history.
Priority #3:
adequate nutrition and
fluid balance.
 Recommend seeing
their primary care
physician if symptoms
persist. And consider
seeing a
gastroenterologist
specialist.
(Ackley, Ladwig, & Makic,
2017).
Health promotion and  Eat a balanced diet  Patient will maintain a  https://www.cdc.gov/di
prevention of Type II that is low carb, low healthy diet and abetes/managing/eat-
Diabetes. fat, low salt. And maintain a healthy well.html
increase consumption weight to prevent or (Link to a CDC meal
on vegetables, dairy, delay Type II Diabetes. guide)
and whole grains.  Patient’s blood sugar  To conserve costs (a
 Eat small frequent and A1C will begin to be concern of the
meals. moniored. patient’s) I recommend
 Avoid cigarette walking/ running at
smoking and drink Glasgow Park for
alcohol in moderation. exercise.
(Asif, 2014). Glasgow Park Trail
 Increase physical Glasgow, DE 19702
activity to 150 minutes  https://smokefree.gov/
per week (30 minutes Smoking cessation
per day). information and tips
(CDC, 2018).
 Need for smoking Health promotion by  Provide infromation and
cessation per client. means of smoking refer patient to
Patient states he smokes cessation. resources on smoking
roughly 1 pack of cessation.
cigarettes per week.  Encourage patient to  Patient will report new
Patient has a family take steps in decreasing
history of lung cancer stress and finding
which increases the coping mechanisms.
patients risk.  Provide positive
feedback for
accomplishments.
(Ackley, Ladwig, &
Makic, 2017).
 Patient will report  https://smokefree.gov
decreased incidence of /
smoking and/or Smoking cessation
complete cessation. information and tips.
Including stress relief
coping mechanisms for information.
stress.  https://www.cvs.com/
minuteclinic/resources
/smoking-cessation
Patient can go into
local CVS to discuss
smoking cesstion with
a nurse practitioner for
coaching and nicotine
replacement
recommendations.

References
Ackley, B., Ladwig, G., & Makic, M. (2017). Nursing diagnosis handbook: an evidence-based guide to planning care (11th ed). St.
Louis, Missouri: Elsvier, Inc.
Asif, M. (2014). The prevention and control the type-2 diabetes by changing lifestyle and dietary pattern. Retrieved from
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3977406/
Centers for Disease Control and Prevention. (2018). Prediabetes: your chance to prevent type 2 diabetes. Retrieved from
https://www.cdc.gov/diabetes/basics/prediabetes.html